Frugal Friends

Request Date:

Amount Requested:

Referred By:

Your Name:

Date of Birth

Street Address:

City:

State

Zip:

Phone Number

SSN:

Description of Request

Names/Ages of all Household Members

Other Agencies Contacted:

Date of Agency Contact:

Has DUMC assisted you within the last 12 months?

Yes

No

To whom should funds be issued?

Address for funds to be issued:

Opt-In

By checking this box, I indicate that I understand that DUMC works in cooperation with Department of Social Services, local Christian Ministrxies and other agencies, and DUMC may discuss personal information that I provide with them with the objective to maximize the use of existing resources for my specific needs. I verify that the household members listed on this form reside at my address. I release DUMC to contact any property owner, landlord, agency or utility company in regard to the funds requested on this form.

Benevolence Fund Financial Request Form

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